Dr Nederlof and Partners Also known as Riverside Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments. The practice had effective systems in place to identify and support carers. The needs of carers were assessed and met. They supported their health and wellbeing needs and ensured they were invited for health checks. The practice took part in an initiative that aimed to diagnose patients with asymptomatic atrial fibrillation (irregular heartbeat without any symptoms) and improve prevalence. They reviewed patients with cardiovascular disease (CVD) or those at risk of CVD to ensure they met their cholesterol targets, and their blood pressure was managed. They raised awareness of atrial fibrillation through a variety of methods including on their website, on posters and on their monthly noticeboard.

The practice planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. For example, regular clinical meetings although these were not as regular for the nursing team. The remote clinical searches we undertook of the practice’s clinical records system showed the monitoring of people with long-term conditions were followed in line with National Institute for Health and Care Excellence (NICE) recommendations.

The practice worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to information they needed to appropriately assess, plan and deliver people’s care, treatment and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff supported national priorities and initiatives to improve population health, including tackling obesity. Health promotion material was available on the information boards in reception and on their website. The practice worked in partnership with other organisations to support patients’ health. For example, they supported a campaign that helped to encourage people with dementia symptoms to seek help. The campaign helped to reduce fear around the condition and highlight available support. National GP Patient Survey data showed that 69% of respondents found the healthcare professional they saw or spoke to was good at considering their mental wellbeing during their last general practice appointment. This was lower than local and national averages. The practice recognised the importance of patient’s mental wellbeing and assigned all members of staff training to support this.

The practice routinely monitored people’s care and treatment to continuously improve it. From the clinical notes we reviewed, we found people who used the service experienced positive outcomes as set out in legislation, standards and evidence-based clinical guidance. Clinical and non-clinical audits were carried out to monitor the quality of care and improve outcomes for patients. For example, they undertook an audit into patients with a new cancer diagnosis who had not had a fast track referral. They used this data to identify learning and trends. Leaders said going forward they were going to do a monthly audit to ensure ongoing learning. At the time of our assessment, the latest information from UK Health Security Agency (UKHSA) showed that the practice did not meet all of the national targets for the number of children immunised against various infectious childhood diseases. The latest information from NHS England showed the practice’s uptake of cervical screening was below the 80% target. However, leaders were aware of this and had put systems in place to improve the uptake. For example, the practice used a butterfly board to promote awareness of cervical cancer screening by adding a butterfly to the wall each time a smear was completed. They also followed up patients who did not attend appointments and invited them opportunistically when they attended for other appointments.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We saw these were clearly documented on patient’s clinical records. Appropriately completed documents were available and had been shared with other relevant services.